Diagnosis of multiple sclerosis: revisions of the McDonald criteria 2017 – continuity and change

Vitamin D levels and olfactory dysfunction in multiple sclerosis patients

OBJECTIVE

The objective was to explore the possible relationship between the serum vitamin D level and olfactory impairment in a population of multiple sclerosis (MS) patients in Guizhou, China.

METHODS

We included 25 patients with MS and 18 healthy controls (HCs) who were recruited from the Affiliated Hospital of Guizhou Medical University from February 2021 to September 2021. The University of Pennsylvania Smell Identification Test (UPSIT) was used to test the patients' sense of smell, and the level of serum 25-hydroxyethylene polyprotein D was measured.

RESULTS

Serum vitamin D levels and UPSIT scores were significantly different between the MS group and the control group (both p < 0.001). Moreover, a significant positive correlation emerged between vitamin D levels and UPSIT scores in MS patients (r = 0.537, p = 0.021).

CONCLUSIONS

The serum vitamin D level may be involved in the regulation of olfactory dysfunction in MS patients in Guizhou, China.

Impaired intestinal permeability in patients with multiple sclerosis

BACKGROUND

A number of recent studies have shown that the intestinal microbiome, part of the brain-gut axis, is implicated in the pathophysiology of multiple sclerosis. An essential part of this axis, is the intestinal barrier and gastrointestinal disorders with intestinal barrier dysregulation appear to be linked to CNS demyelination, and hence involved in the etiopathogenesis of multiple sclerosis (MS).

OBJECTIVE

The aim of this study was to evaluate the integrity of the intestinal barrier in patients with clinically definite multiple sclerosis (CDMS) and clinically isolated syndrome (CIS) using two serum biomarkers, claudin-3 (CLDN3), a component of tight epithelial junctions, and intestinal fatty acid binding protein (I-FABP), a cytosolic protein in enterocytes.

METHODS

Serum levels of CLDN3 in 37 MS patients and 22 controls, and serum levels of I-FABP in 46 MS patients and 51 controls were measured using commercial ELISA kits. Complete laboratory tests excluded the presence of gluten-related disorders in all subjects. Thirty MS patients received either disease-modifying drugs (DMD), immunosuppression (IS) or corticosteroid treatment.

RESULTS

CLDN3 levels were only significantly higher in the MS patients treated with DMD or IS compared to the control group (P=0.006). There were no differences in I-FABP serum levels between the groups. Serum CLDN3 levels did not correlate with serum I-FABP levels in CDMS, in CIS patients or controls.

CONCLUSIONS

In multiple sclerosis patients, the intestinal epithelium may be impaired with increased permeability, but without significant enterocyte damage characterized by intracellular protein leakage. Based on our data, CLDN3 serum levels appear to assess intestinal dysfunction in MS patients but mainly in treated ones.

Reliability parameters of the Timed 25-Foot-Walk (T25FW) in patients with Multiple Sclerosis: Lower walking speed is associated with greater Smallest Detectable Change

BACKGROUND

Reliability parameters of clinical measures should be sufficient in order to adequately monitor disease course and evaluate treatment in patients with Multiple Sclerosis (MS). The aim of this study was to assess the reliability of the Timed 25-Foot-Walk (T25FW) in patients with MS.

METHODS

MS patients performed the T25FW twice with approximately one year in between. After the second measurement, they answered an anchor question using a three-point Likert scale. Taking the non-normal distribution of the T25FW into account, intraclass correlation coefficient (ICCagreement), standard error of the mean (SEMagreement) and smallest detectable change (SDC) were computed.

RESULTS

118 MS patients (76.3 % females, mean age 48.2 years) were included. Of these patients, 73 reported no change on the anchor question. They completed the T25FW at baseline in 4.7s (IQR 4.3-5.4s, n = 72) and at follow-up in 4.9s (IQR 4.3-5.9s, n = 73). The ICCagreement was 0.895, the SEMagreement was 0.037. The SDC was higher for higher mean T25FW and can be computed for each mean T25FW by 0.23*mean T25FW.

CONCLUSION

Overall, in patients with MS, the T25FW has a sufficient reliability as measured with the ICC, however the SDC of the T25FW increased when patients perform worse on the T25FW (i.e. have a lower walking speed). Because this test is often used in MS patients with limited walking ability, these findings are important to keep in mind when interpreting the re-test scores of the T25FW.

Analysis of potential microRNA biomarkers for multiple sclerosis

Multiple sclerosis (MS) is a chronic demyelinating autoimmune neurodegenerative disorder for which no specific blood biomarker is available. MicroRNAs (miRNAs) have been investigated for their diagnostic potential in MS. However, MS-associated miRNAs are rarely replicated in different MS populations, thus impeding their use in clinical testing. Here, we evaluated the fold expression of seven reported MS miRNAs associated with MS incidence and clinical characteristics in 76 MS patients and 75 healthy control plasma samples. We found miR-23a-3p to be upregulated in relapsing-remitting MS (RRMS), while miR-326 was downregulated. MiR-150-5p and -320a-3p were significantly downregulated in secondary progressive MS (SPMS) patients compared to RRMS. High disability was associated with low miR-320a-3p, whereas low BDNF levels were associated with upregulation of miR-150-5p and downregulation of miR-326 expression in the total cohort. MiR-23a-3p and miR-326 showed significant diagnostic sensitivity, specificity, and accuracy for RRMS diagnosis. In addition, miR-150-5p and miR-320a-3p had comparable significant diagnostic test performance metrics distinguishing SPMS from RRMS. Therefore, there is potential for including miR-23a-3p and miR-326 in an RRMS diagnostic miRNA panel. Moreover, we have shown that miR-150-5p and miR-320a-3p could be novel RRMS conversion to SPMS biomarkers. The use of these miRNAs in MS diagnosis and prognosis warrants further investigation.

Building digital patient pathways for the management and treatment of multiple sclerosis

Recent advances in the field of artificial intelligence (AI) could yield new insights into the potential causes of multiple sclerosis (MS) and factors influencing its course as the use of AI opens new possibilities regarding the interpretation and use of big data from not only a cross-sectional, but also a longitudinal perspective. For each patient with MS, there is a vast amount of multimodal data being accumulated over time. But for the application of AI and related technologies, these data need to be available in a machine-readable format and need to be collected in a standardized and structured manner. Through the use of mobile electronic devices and the internet it has also become possible to provide healthcare services from remote and collect information on a patient's state of health outside of regular check-ups on site. Against this background, we argue that the concept of pathways in healthcare now could be applied to structure the collection of information across multiple devices and stakeholders in the virtual sphere, enabling us to exploit the full potential of AI technology by e.g., building digital twins. By going digital and using pathways, we can virtually link patients and their caregivers. Stakeholders then could rely on digital pathways for evidence-based guidance in the sequence of procedures and selection of therapy options based on advanced analytics supported by AI as well as for communication and education purposes. As far as we aware of, however, pathway modelling with respect to MS management and treatment has not been thoroughly investigated yet and still needs to be discussed. In this paper, we thus present our ideas for a modular-integrative framework for the development of digital patient pathways for MS treatment.

Monitoring of the pharmacological treatment availability in patients with multiple sclerosis in the Greater Poland population

Introduction

There is no clear explanation for the availability of multiple sclerosis (MS) pharmacological treatment for patients in Greater Poland and it can be assumed that the same reason is common in most of the developed countries in the United Europe. As an autoimmune disease MS can overlap with other diseases especially rheumatic disease (RD) as well as some feature of RD may mimic MS, such as MS-like syndrome in the course of primary Sjögren's syndrome. Therefore proper diagnosis and sufficient treatment of MS is important not only for neurologists but also for other clinicians including rheumatologists.The study aims to provide insights that could help healthcare managers create more effective logistical guidelines to improve the timely initiation of pharmacological treatment for MS.

Materials and methods

The analysis of the treatment of MS patients has been conducted on a group of 500 patients who were under the management of one healthcare center in Greater Poland.

Results

The results point to the different factors influencing the delay in the undertaking the pharmacological treatment, among others the age of the patient, waiting time for clinical evaluation and the final diagnosis from first symptoms to diagnosis, and the patient's waiting time from diagnosis to referral for qualification for treatment.

Conclusions

The outcomes of this study have the potential to serve as a valuable resource for healthcare managers. The study's findings could be used as a foundation for developing logistical guidelines aimed at enhancing the pharmacological treatment of MS patients.Furthermore, the study suggests that the reasons behind treatment delays in MS patients might be prevalent in many countries across the United Europe region. However, it's important to note that confirming this conclusion requires additional comparative studies.

Cerebrospinal fluid oligoclonal bands in Chinese patients with multiple sclerosis: the prevalence and its association with clinical features

Background

Cerebrospinal fluid oligoclonal band (CSF-OCB) is an established biomarker in diagnosing multiple sclerosis (MS), however, there are no nationwide data on CSF-OCB prevalence and its diagnostic performance in Chinese MS patients, especially in the virtue of common standard operation procedure (SOP).

Methods

With a consensus SOP and the same isoelectric focusing system, we conducted a nationwide multi-center study on OCB status in consecutively, and recruited 483 MS patients and 880 non-MS patients, including neuro-inflammatory diseases (NID, n = 595) and non-inflammatory neurological diseases (NIND, n=285). Using a standardized case report form (CRF) to collect the clinical, radiological, immunological, and CSF data, we explored the association of CSF-OCB positivity with patient characters and the diagnostic performance of CSF-OCB in Chinese MS patients. Prospective source data collection, and retrospective data acquisition and statistical data analysis were used.

Findings

369 (76.4%) MS patients were OCB-positive, while 109 NID patients (18.3%) and 6 NIND patients (2.1%) were OCB-positive, respectively. Time from symptom onset to diagnosis was significantly shorter in OCB-positive than that in OCB-negative MS patients (13.2 vs 23.7 months, P=0.020). The prevalence of CSF-OCB in Chinese MS patients was significantly higher in high-latitude regions (41°-50°N)(P=0.016), and at high altitudes (>1000m)(P=0.025). The diagnostic performance of CSF-OCB differentiating MS from non-MS patients yielded a sensitivity of 76%, a specificity of 87%.

Interpretation

The nationwide prevalence of CSF-OCB was 76.4% in Chinese MS patients, and demonstrated a good diagnostic performance in differentiating MS from other CNS diseases. The CSF-OCB prevalence showed a correlation with high latitude and altitude in Chinese MS patients.

Synthesis and bioactivity evaluation of a myelin-specific contrast agent for magnetic resonance imaging of myelination in central nervous system

Demyelination exists in many neurological diseases of nervous system, such as stroke. Currently, magnetic resonance imaging (MRI) has been the main tool for diagnosing and monitoring the myelin related diseases. However, the conventional MRI unable to distinguish demyelinating lesions from other inflammatory lesions. To address this problem, we have designed and prepared a myelin specific magnetic resonance contrast agent, Gd-DTDAS, which was based myelin specific moiety MeDAS^g and Gd-DTPA^h. In this work, we verified the specificity and sensitivity of Gd-DTDAS to myelin. Moreover, we investigated the specific binding ability of Gd-DTDAS to myelin sheath in the MCAO miceⁱ models. The in vivo imaging results showed that Gd-DTDAS can bind to the undamaged myelin sheath in the BBB disruption areas, and in turn reduce the relaxation time. The fluorescence images also showed significant fluorescence in the brain right infarct area of the MCAO model mice with administration of Gd-DTDAS. The above results confirmed that Gd-DTDAS could be preferentially distributed in areas with high myelination and can detect focally induced demyelination.

Reliability, validity and clinical usability of a robotic assessment of finger proprioception in persons with multiple sclerosis

BACKGROUND

Multiple sclerosis often leads to proprioceptive impairments of the hand. However, it is challenging to objectively assess such deficits using clinical methods, thereby also impeding accurate tracking of disease progression and hence the application of personalized rehabilitation approaches.

OBJECTIVE

We aimed to evaluate test-retest reliability, validity, and clinical usability of a novel robotic assessment of hand proprioceptive impairments in persons with multiple sclerosis (pwMS).

METHODS

The assessment was implemented in an existing one-degree of freedom end-effector robot (ETH MIKE) acting on the index finger metacarpophalangeal joint. It was performed by 45 pwMS and 59 neurologically intact controls. Additionally, clinical assessments of somatosensation, somatosensory evoked potentials and usability scores were collected in a subset of pwMS.

RESULTS

The test-retest reliability of robotic task metrics in pwMS was good (ICC=0.69-0.87). The task could identify individuals with impaired proprioception, as indicated by the significant difference between pwMS and controls, as well as a high impairment classification agreement with a clinical measure of proprioception (85.00-86.67%). Proprioceptive impairments were not correlated with other modalities of somatosensation. The usability of the assessment system was satisfactory (System Usability Scale ≥73.10).

CONCLUSION

The proposed assessment is a promising alternative to commonly used clinical methods and will likely contribute to a better understanding of proprioceptive impairments in pwMS.

Ocrevus reduces TH40 cells, a biomarker of systemic inflammation, in relapsing multiple sclerosis (RMS) and in progressive multiple sclerosis (PMS)

Treating MS has been difficult. One successful drug is Ocrelizumab (anti-CD20), used for the chronic relapsing MS (RMS) and the progressive MS (PMS) forms. TH40 cells are pathogenic effector T cells that increase in percentage and numbers during chronic inflammation. Here we show that in the earliest MS course, clinically isolated syndrome (CIS), TH40 cells expand in number. In PMS TH40 cell numbers remain expanded demonstrating sustained chronic inflammation. In RMS TH40 cells were found in CSF and express CD20. Ocrelizumab reduced TH40 cells to healthy control levels in patients. During treatment inflammatory cytokine producing TH40 cells were decreased.

The borderland of multiple sclerosis and functional neurological disorder: A call for clinical research and vigilance

BACKGROUND AND PURPOSE

Functional neurological disorders (FNDs) have attracted much attention from the neurological medical community over the last decades as new developments in neurosciences have reduced stigma around these by showing brain network dysfunctions. An overlap with other neurological conditions such as multiple sclerosis (MS) is well known by clinicians but there is a lack of clinical and fundamental research in this field to better define diagnosis and therapeutic decisions, as well as a lack of deep understanding of the underlying pathophysiology.

AIM

We aimed to provide a critical commentary on the state of knowledge about the borderland between FNDs and MS.

METHODS

We based our commentary on a joint point of view between an FND specialist and an MS expert.

RESULTS

A brief review of the previous literature and relevant new studies covering the overlap between FNDs and MS is presented, along with suggestions for future research directions.

CONCLUSION

There are clear diagnostic criteria for both FNDs and MS and a strict application of these will help better diagnosis and prevent unnecessary treatment escalation in MS or absence of referral to multimodal therapy in FND. Better teaching of younger neurologists is needed as well as prospective research focusing on pathophysiology.

Progress in Mechanism of Astragalus membranaceus and Its Chemical Constituents on Multiple Sclerosis

The primary chemical components of Astragalus membranaceus include polysaccharides, saponins, flavonoids, and amino acids. Recent studies have shown that Astragalus membranaceus has multiple functions, including improving immune function and exerting antioxidative, anti-radiation, anti-tumor, antibacterial, antiviral, and hormone-like effects. Astragalus membranaceus and its extracts are widely used in clinical practice because they have obvious therapeutic effects against various autoimmune diseases and relatively less adverse reaction. Multiple sclerosis (MS) is an autoimmune disease of central nervous system (CNS), which mainly caused by immune disorder that leads to inflammatory demyelination, inflammatory cell infiltration, and axonal degeneration in the CNS. In this review, the authors analyzed the clinical manifestations of MS and experimental autoimmune encephalomyelitis (EAE) and focused on the efficacy of Astragalus membranaceus and its chemical components in the treatment of MS/EAE.

Improvement in time to multiple sclerosis diagnosis: 25-year retrospective analysis from New York State MS Consortium (NYSMSC)

Judicious multiple sclerosis (MS) diagnosis and early start of disease modifying therapy significantly improves long-term disability outcomes in persons with MS (pwMS). Retrospective analysis based on 25-year New York State MS Consortium (NYSMSC) data determined the effect of changes in the respective diagnostic criteria in shortening the time between symptom onset to MS diagnosis. Based on 9378 current and historical MS cases, there was a significant decrease in time to diagnosis in pwMS from 1982–2001 to >2017 periods (average 4.2 vs. 1.1 years, p < 0.001). Additional improvements and better implementation of the MS diagnostic criteria can further decrease the diagnosis lag.

Burden and trends of multiple sclerosis in China from 1990 to 2019: a systematic analysis for the Global Burden of Disease Study 2019

OBJECTIVE

To compare the burden of multiple sclerosis disease indicators in the Asia-Pacific countries, China and globally through the Global Burden of Disease 2019 (GBD2019) Database, and to analyse the changes of multiple sclerosis disease burden in China from 1990 to 2019.

STUDY DESIGN

Observational study based on the Global Burden of Disease.

SETTING

The relevant incidence, prevalence, death and disability-adjusted life year (DALY) rates and corresponding age-standardised rates (ASRs) and sociodemographic index (SDI) in China, globally and in Asia-Pacific countries were extracted from the GBD2019 Database to further study the age-standardised incidence, prevalence and mortality, and the relationship between DALY rate and SDI.

RESULTS

Various disease burden indicators of multiple sclerosis in China are at low level in the world, and the prevalence, incidence and DALY rates have slowly increased from 1990 to 2019. During this period, the age-standardised prevalence rate (ASPR) of multiple sclerosis in China showed an upward trend, while the age-standardised death rate (ASDR), age-standardised DALY rate (ASR-DALY) and age-standardised incidence rate all decreased to varying degrees, which were roughly consistent with the global amplitude changes, and all indicators are similar to most countries in the Asia-Pacific region. As the value of the SDI increases, the ASPR of multiple sclerosis was trending upward, and the ASDR was trending downward.

CONCLUSION

Compared with other countries in the Asia-Pacific region, China is in a low state of disease burden indicators. However, as a developing country and the most populous country in the world, the total number of patients is not small, and as a rare disease, the treatment cost is relatively expensive, and the treatment cost of the complications caused by the disease is not low. The construction of the medical security system should be strengthened to reduce its burden on individuals, families and society.

MIF in the cerebrospinal fluid is decreased during relapsing-remitting while increased in secondary progressive multiple sclerosis

BACKGROUND

Macrophage migration inhibitory factor (MIF) is involved in the function of both the innate and adaptive immune systems and in neuroprotection and has recently been implicated in multiple sclerosis (MS).

OBJECTIVES

Determination of MIF levels in the cerebrospinal fluid (CSF) of patients with distinct subtypes of MS and the cellular localization of MIF in human brain tissue.

METHODS

The levels of MIF were investigated in CSF from patients with clinically isolated syndrome (CIS) (n = 26), relapsing-remitting MS (RRMS) (n = 22), secondary progressive MS (SPMS) (n = 19), and healthy controls (HCs) (n = 24), using ELISA. The effect of disease-modifying therapies in the RRMS and SPMS cohorts were examined. Cellular distribution of MIF in the human brain was studied using immunochemistry and the newly available OligoInternode database.

RESULTS

MIF was significantly decreased in treatment-naïve CIS and RRMS patients compared to HCs but was elevated in SPMS. Interestingly, MIF levels were sex-dependent and significantly higher in women with CIS and RRMS. MIF expression in the human brain was localized to neurons, astrocytes, pericytes, and oligo5 oligodendrocytes but not in microglia.

CONCLUSION

The finding that MIF was decreased in newly diagnosed CIS and RRMS patients but was high in patients with SPMS may suggest that MIF levels in CSF are regulated by local MIF receptor expression that affects the overall MIF signaling in the brain and may represent a protective mechanism that eventually fails.

Determining the minimal important change of the 6-minute walking test in Multiple Sclerosis patients using a predictive modelling anchor-based method

BACKGROUND

The minimal important change (MIC) of the 6-minute walk test (6MWT) is not clear for patients with Multiple Sclerosis (MS), hampering treatment evaluation. The aim of our study was therefore to determine the MIC of the 6MWT in MS patients.

METHODS

MS patients did the 6MWT using the instruction to walk at comfortable speed twice with approximately one year in between. After the second 6MWT they completed 3-point anchor question. The MIC_adjusted with a 95% confidence interval (CI) was calculated with the predictive modelling method with bootstrapping.

RESULTS

118 MS patients (mean age 48.2 years, 23.7% men) were included between September 2018 and October 2019. Mean 6MWT distance was 468 ± 112 m at baseline and 469 ± 115 m one year later. Twenty-three (19.5%) patients answered their walking distance improved, 43 (36.4%) answered it worsened. A MIC_adjusted for improvement of 19.7 m (95%CI 9.8-30.9 m) was found, and for deterioration of 7.2 m (95%CI -3.3-18.2 m).

CONCLUSIONS

Using the most sophisticated statistical method, the MIC_adjusted of the 6MWT in MS patients was 19.7 m for improvement, and 7.2 m for deterioration. This knowledge allows physiotherapists and physicians to evaluate if their treatment has led to a meaningful improvement for their MS patients or if walking of their patients has deteriorated.

Discovery of Novel Biomarkers for Diagnosing and Predicting the Progression of Multiple Sclerosis Using TMT-Based Quantitative Proteomics

Objective

Here, we aimed to identify protein biomarkers that could rapidly and accurately diagnose multiple sclerosis (MS) using a highly sensitive proteomic immunoassay.

Methods

Tandem mass tag (TMT) quantitative proteomic analysis was performed to determine the differentially expressed proteins (DEPs) in cerebrospinal fluid (CSF) samples collected from 10 patients with MS and 10 non-inflammatory neurological controls (NINCs). The DEPs were analyzed using bioinformatics tools, and the candidate proteins were validated using the ELISA method in another cohort comprising 160 samples (paired CSF and plasma of 40 patients with MS, CSF of 40 NINCs, and plasma of 40 healthy individuals). Receiver operating characteristic (ROC) curves were used to determine the diagnostic potential of this method.

Results

Compared to NINCs, we identified 83 CSF-specific DEPs out of a total of 343 proteins in MS patients. Gene ontology (GO) enrichment analysis revealed that these DEPs are mainly involved in platelet degranulation, negative regulation of proteolysis, and post-translational protein modification. Pathway enrichment analysis revealed that the complement and coagulation cascades, Ras signaling pathway, and PI3K-Akt signaling pathway are the main components. Insulin-like growth factor-binding protein 7 (IGFBP7), insulin-like growth factor 2 (IGF2), and somatostatin (SST) were identified as the potential proteins with high scores, degree, and centrality in the protein-protein interaction (PPI) network. We validated the expression of these three proteins using ELISA. Compared to NINCs, the level of CSF IGFBP7 was significantly upregulated, and the level of CSF SST was significantly downregulated in the MS group.

Conclusion

Our results suggest that SST and IGFBP7 might be associated with the pathogenesis of MS and would be helpful in diagnosing MS. Since IGFBP7 was used to classify relapsing remitting MS (RRMS) and secondary progressive MS (SPMS) patients, therefore, it may act as a potential key marker and therapeutic target in MS.

Perspectives on urological care in multiple sclerosis patients

Multiple sclerosis (MS) is a chronic autoimmune disease of the central nervous system. Lower urinary tract dysfunction due to MS includes a dysfunction of the storage phase or dysfunction of the voiding phase or a detrusor-sphincter dyssynergia. Baseline evaluation includes a voiding chart, an ultrasound scan of the urinary tract, urine culture, and an urodynamic study. For storage symptoms, antimuscarinics are the first-line treatment, and clean intermittent catheterization (CIC) is indicated if there is concomitant incomplete bladder emptying. Intradetrusor injections with botulinum toxin A (BTX-A), are recommended for refractory cases. Urinary diversion is rarely indicated. For patients with voiding symptoms, CIC and alpha-blockers are usually offered. Sexual dysfunction in patients with MS is multifactorial. Phosphodiesterase type 5 inhibitors are first-line therapies for MS-associated erectile dysfunction in both male and female patients. This review summarizes the epidemiology, pathogenesis, risk factors, genetic, clinical manifestations, diagnostic tests, and management of MS. Lastly, the urologic outcomes and therapies are reviewed.

Perceived discrimination in patients with multiple sclerosis and depressive symptomatology

BACKGROUND

Multiple Sclerosis is the central nervous system's most common demyelinating disease and the second leading cause of neurological disability in young adults. Its natural development involves physical and cognitive impairment. Patients commonly perceive discrimination against them, regardless of its occurrence, accepting it as an inherent part of the disease.

OBJECTIVE

This study aimed to determine the association between perceived discrimination and the depressive symptoms and physical disability present in patients diagnosed with multiple sclerosis, treated at the Demyelinating Diseases Clinic of the National Institute of Neurology and Neurosurgery, Manuel Velasco Suárez.

METHODS

A cross-sectional study was conducted in 98 patients diagnosed with multiple sclerosis. Demographic and clinical variables were obtained through clinical interviews. The severity of the disease was determined using the Extended Disability Status Scale (EDSS), depressive symptoms were assessed with the Beck Depression Inventory (BDI), and perceived discrimination was rated using the King Internalized Stigma Scale.

RESULTS

The studied sample's mean age was 36.3 years, schooling 13.6 years, symptoms onset was at 26.2 years (with a delay in diagnosis of 3.2 years), and a disease evolution of 10.9 years. 71.4% were single; 52% had an unpaid work activity and 57.1% were women. The EDSS average was 3.5 points; 24.5% presented moderate to severe depressive symptoms and 53.1% referred perceived discrimination.

CONCLUSIONS

Perceived discrimination in patients with multiple sclerosis was associated with earlier disease onset, depressive symptoms, and the lack of caregivers. Medical care and life quality improvement for this vulnerable group require greater education regarding the disease and the establishment of patient support programs.

Subgroup analysis of clinical and MRI outcomes in participants with a first clinical demyelinating event at risk of multiple sclerosis in the ORACLE-MS study

BACKGROUND

In the Phase 3, 96-week ORACLE-MS study, cladribine 10 mg tablets (3.5 mg/kg or 5.25 mg/kg cumulative dose over 2 years) significantly reduced the rate of conversion to clinically definite multiple sclerosis (CDMS) per the Poser criteria (henceforth referred to as CDMS), multiple sclerosis (MS) per the 2005 McDonald criteria, and the number of new or persisting T1 gadolinium-enhancing (Gd+), new or enlarging T2, and combined unique active (CUA) lesions versus placebo in participants with a first clinical demyelinating event (FCDE). Patient demographic and disease characteristics may be predictors of disease progression. The current study analyzed the effect of cladribine tablets in subgroups of participants in the ORACLE-MS study by baseline demographics and disease characteristics.

METHODS

This analysis retrospectively examined data collected from 616 participants enrolled in the ORACLE-MS study (placebo, n=206; cladribine tablets 3.5 mg/kg, n=206; cladribine tablets 5.25 mg/kg, n=204). Five subgroups were predetermined by baseline demographics, including sex, age (<30 or ≥30 years), classification of FCDE, and lesion characteristics, including absence or presence of T1 Gd+ lesions and number of T2 lesions (<9 or ≥9). Selected endpoints of the ORACLE-MS study were re-analyzed for these subgroups. The primary and main secondary endpoints were time to conversion to CDMS and MS (2005 McDonald criteria), respectively. Secondary magnetic resonance imaging (MRI) endpoints included cumulative T1 Gd+ and new or enlarging T2 lesions. Cox proportional hazards models were used to evaluate time to conversion to CDMS and MS (2005 McDonald criteria). This analysis focused primarily on the results for the cladribine tablets 3.5 mg/kg group because this dosage is approved for relapsing forms of MS.

RESULTS

In the overall intent-to-treat (ITT) population, cladribine tablets 3.5 mg/kg significantly reduced the risk of conversion to CDMS (hazard ratio [HR]=0.326; P<0.0001) and MS (2005 McDonald criteria; HR=0.485; P<0.0001) versus placebo. Similar effects of cladribine tablets on risk of conversion were observed in post hoc analyses of subgroups defined by various baseline characteristics. In both the ITT population and across subgroups, cladribine tablets 3.5 mg/kg reduced the numbers of cumulative T1 Gd+ (range of rate ratios: 0.106-0.399), new or enlarging T2 (range of rate ratios: 0.178-0.485), and CUA (range of rate ratios: 0.154-0.384) lesions versus placebo (all nominal P<0.03). Multivariate Cox proportional hazards models revealed that age (HR=0.577, nominal P<0.0001), FCDE classification (HR=0.738, nominal P=0.0043), presence of T1 Gd+ lesions (HR=0.554, nominal P<0.0001), and number of T2 lesions (HR=0.417, nominal P<0.0001) at baseline were factors associated with risk of conversion to MS (2005 McDonald criteria), whereas no baseline factors examined were associated with risk of conversion to CDMS.

CONCLUSION

In this post hoc analysis of the ORACLE-MS study, cladribine tablets reduced the risk of conversion to multiple sclerosis and lesion burden in participants with an FCDE in the overall ITT population and multiple subgroups defined by baseline demographics and lesion characteristics.

Retrospective evaluation of regional telemedicine team meetings for multiple sclerosis (MS) patients: Experience from the Caen MS expert center in Normandy, France

INTRODUCTION

Multiple sclerosis (MS) is a demyelinating disease requiring multidisciplinary care coordination. Recent development of diagnosis criteria and disease modifying treatments have encouraged the setup of regional team meetings by MS expert centers, known as CRC Sep, to improve the quality of care provided to patients with complex cases. The CRC Sep in Caen initiated regional telemedicine meetings named Télé-SEP, operating since 2016. The objective of this study was to evaluate the Télé-SEP used by neurologists, on MS patient care management in Normandy.

METHODS

An internal ex-itinere evaluation was conducted with a retrospective descriptive observational study from July 2016 to June 2018. The Télé-SEP meetings were organized with 41 neurologists using a regional telemedicine platform (Therap-e). Data were collected from online records and a declarative voluntary survey. Twenty indicators were classified in the categories: volume of activity, clinical profile, quality and impact.

RESULTS

Fifteen meetings were organized with a median of 13 senior neurologists. One hundred forty MS cases were discussed and there was a 33% increase in the second year of Télé-SEP. Median patient age was 44 years with a 72-month median length of disease. Most patient cases required second-line treatment. Relapsing remitting MS was diagnosed in 51.4% of cases. Télé-SEP satisfaction rate was 4.5/5 and 96% of neurologists applied the medical decisions and recommendations given in the meetings.

CONCLUSION

Without Télé-SEP, 54.5% of patients would have been referred to a physical expert consultation in the CRC Sep. This study showed the feasibility and relevance of regional telemedicine team meetings for MS cases in the Normandy region.

Retinal thinning and brain atrophy in early MS and CIS

BACKGROUND

Optical coherence tomography (OCT) could be complementary to magnetic resonance imaging (MRI) of the brain in monitoring course of multiple sclerosis (MS) and clinically isolated syndrome (CIS). Thinning of neurons in ganglion cell-inner plexiform layer (GCIPL) measured by OCT is assumed to be associated with brain atrophy.

OBJECTIVES

To evaluate association of GCIPL with brain parameters detected by quantitative MRI (qMRI) and MR-spectroscopy (MRS) in early MS and CIS.

METHODS

Seventeen newly diagnosed MS and 18 CIS patients were prospectively included. The patients were assessed at baseline as well as at 1 year follow-up by OCT, qMRI and MRS. Brain parenchymal and myelin volumes (BPV, MYV respectively) and the corresponding fractions (BPF, MYF) were measured with qMRI. Metabolites including myo-inositol (myo-Ins) were measured in the normal-appearing white matter (NAWM) using MRS. T-tests and ANOVA were used to analyze group differences, and linear regression models to evaluate association of GCIPL with BPV, MYV and myo-Ins after correlation analysis.

RESULTS

Disease activity reflected by lesions on MRI and presence of CSF oligoclonal IgG bands were more prominent in MS compared to CIS. GCIPL, BPV, MYV, BPF and MYF were reduced, while concentration of myo-Ins was increased in MS compared to CIS. Follow-up showed consistency of thinner GCIPL in MS compared to CIS. GCIPL thinning correlated with reduced BPV and MYV (P < .05 for both), but with increased myo-Ins (P < .01).

CONCLUSIONS

Significant GCIPL thinning occurs in early MS and is associated with enhanced brain inflammation and atrophy.

Monitoring the Redox Status in Multiple Sclerosis

Worldwide, over 2.2 million people suffer from multiple sclerosis (MS), a multifactorial demyelinating disease of the central nervous system. MS is characterized by a wide range of motor, autonomic, and psychobehavioral symptoms, including depression, anxiety, and dementia. The blood, cerebrospinal fluid, and postmortem brain samples of MS patients provide evidence on the disturbance of reduction-oxidation (redox) homeostasis, such as the alterations of oxidative and antioxidative enzyme activities and the presence of degradation products. This review article discusses the components of redox homeostasis, including reactive chemical species, oxidative enzymes, antioxidative enzymes, and degradation products. The reactive chemical species cover frequently discussed reactive oxygen/nitrogen species, infrequently featured reactive chemicals such as sulfur, carbonyl, halogen, selenium, and nucleophilic species that potentially act as reductive, as well as pro-oxidative stressors. The antioxidative enzyme systems cover the nuclear factor erythroid-2-related factor 2 (NRF2)-Kelch-like ECH-associated protein 1 (KEAP1) signaling pathway. The NRF2 and other transcriptional factors potentially become a biomarker sensitive to the initial phase of oxidative stress. Altered components of the redox homeostasis in MS were discussed in search of a diagnostic, prognostic, predictive, and/or therapeutic biomarker. Finally, monitoring the battery of reactive chemical species, oxidative enzymes, antioxidative enzymes, and degradation products helps to evaluate the redox status of MS patients to expedite the building of personalized treatment plans for the sake of a better quality of life.

Application of the 2017 McDonald criteria in a Chinese population with clinically isolated syndrome

Background:

Diagnostic criteria for multiple sclerosis have evolved over time, with the most recent being the 2017 McDonald criteria. Evidence is lacking regarding the validity of the 2017 McDonald criteria among the Asian population. Therefore, this study aims to evaluate the diagnostic performance of the 2017 McDonald criteria in Chinese patients with clinically isolated syndrome (CIS).

Methods:

A total of 93 patients with initial findings suggestive of CIS in a tertiary hospital in China from 2012 to 2017 were included in this retrospective study. Baseline and follow-up data were reviewed. Diagnostic performance (sensitivity, specificity, accuracy), was assessed and survival analysis was performed for the 2017 and 2010 McDonald criteria respectively.

Results:

Among the 93 Chinese patients with CIS, 57 were female (61.3%) and the median (interquartile range) age of onset was 37 (31.3–41.8) years. The 2017 McDonald criteria displayed a higher sensitivity (75.0% versus 14.6%, p < 0.0001), lower specificity (47.1% versus 100.0%, p < 0.05) but an overall higher accuracy (67.7% versus 36.9%, p < 0.0001) when compared with the 2010 iteration. The novel criteria allow for a better detection of MS at baseline (40.8% versus 9.9%, p < 0.0001).

Conclusion:

The 2017 McDonald criteria had a higher sensitivity but lower specificity than the 2010 iteration. Overall it facilitated an earlier and more accurate diagnosis of multiple sclerosis in Chinese patients with CIS.

Clinical and radiologic approach to 'typical' versus antibody-related optic neuritis

PURPOSE OF REVIEW

Optic neuritis is an autoimmune optic neuropathy that has been associated with multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD), and more recently antimyelin oligodendrocyte glycoprotein (anti-MOG)-positive disorder. At initial presentation, it is often difficult to differentiate these entities given their significant overlap in clinical presentation and MRI findings. This review summarizes the distinguishing clinical and radiological features of MS, NMOSD, and anti-MOG disorders to help clinicians accurately diagnose and manage patients affected by these conditions.

RECENT FINDINGS

Antiaquaporin-4 (AQP4) and more recently anti-MOG antibodies are both associated with central nervous system demyelinating diseases that often initially present with optic neuritis. Serologic testing now allows for a new classification of these overlapping conditions that can help to differentiate 'typical' optic neuritis that is often associated with MS from 'atypical' optic neuritis associated with NMOSD and anti-MOG-positive disorder.

SUMMARY

Optic neuritis associated with MS, NMOSD, and anti-MOG-positive disease can have a similar clinical presentation. However, some clinical and radiologic findings can help clinicians to differentiate these entities so that they can be properly managed to optimize visual prognosis.